NCMB 312 RLE Surgical Scrubbing, Gowning and Gloving PDF

NCMB312 RLE WEEK 1 PROFESSOR: MS. FLOR JAVIER LINA 3RD YEAR 1ST SEM 2023 Day 1 : Surgical Scrubbing, Gowning and Gloving Materials Surgical Scrubbing...

NCMB312 RLE WEEK 1 PROFESSOR: MS. FLOR JAVIER LINA 3RD YEAR 1ST SEM 2023 Day 1 : Surgical Scrubbing, Gowning and Gloving Materials Surgical Scrubbing Brush Medical Asepsis vs. Surgical Asepsis Antimicrobial Types of Surgical Scrubbing A. Time Method Complete Scrub – 5-7 minutes Short Scrub – 3 minutes Implementation B. Brush Stroke Method 1. Don surgical shoe covers, cap, or hood, face mask, Nails – 30 Strokes and protective eyewear. Side Of Fingers – 20 Strokes 2. Perform pre scrub wash at beginning of work shift. Back Of The Hand – 20 Strokes a. Turn water on using foot or knee control and Arms – 20 Strokes adjust to a comfortable temperature. b. Wet hands thoroughly with water. Follow Purpose manufacturer directions for application of - To protect healthcare workers and clients from soap. transmission of potentially infectious materials c. Rubbed hands, covering all surfaces with - To prevent wound infection lather, including backs of hands, fingertips, inner webs, and palms, washing for at least Assessment 15 seconds. 1. Determine type and length of time for hand hygiene. d. Rinse hands well. Dry hands thoroughly with 2. Remove bracelets, rings and watches. disposable towel and discard towel. 3. Inspect fingernails, which must be short (2mm), clean, 3. Surgical hand scrub (with sponge). and healthy. Check with the agency policy to see if a. Turn on water using foot or knee control. fingernail polish was permitted. Do not wear artificial Clean under nails of both hands with nails or extenders. disposable nail pick or cleaner. Rinse hands 4. Inspect condition of cuticles, hands, and forearms for and forearms under running water, keeping presence of abrasions, cuts, or open lesions. hands and forearms elevated and elbows down. Planning b. Dispense antimicrobial scrub agents - Determine expected outcomes following completion of according to manufacturer instructions. procedure. Apply the agent to wet hands and forearms with soft, nonabrasive sponge. c. Scrub for the length of time recommended by the manufacturer. Visualize each finger,  hand, and arms as having four sides. Wash Surgical Gowning and Gloving all four sides effectively, keeping hand Purpose elevated, elbow down. Repeat for the other - To protect healthcare workers and clients from hand, fingers, and arm. transmission of potentially infectious materials d. Avoid splashing surgical attire. Discard - To prevent wound infection sponges in the appropriate container. Assessment e. Rinse hands and arms, running water from 1. Select proper size and type of sterile gloves. Select fingertips to elbows in one continuous latex-free gloves if you know that patient or any motion, holding hands higher than elbows surgical personnel in the room are latex sensitive. and away from the surgical site. 2. Select the proper size and type of sterile surgical f. Turn off water using foot or knee controls gown. and back into OR holding hands higher than elbows and away from surgical attire. Planning g. Approach sterile setup and grasped sterile - Determine expected outcomes following completion of towel, taking care not to drip water on sterile procedure. field. h. Keeping hands and arms above waist and Implementation outstretched, carefully grasp one end of the 1. Don sterile gown: sterile towel to dry one hand thoroughly, a. Open a sterile gown and glove package on a moving from fingers to elbow in rotating clean, dry, flat surface. A scrub nurse can do motion. this, preferably on a small table separate i. Use the opposite end of the towel to dry the from sterile fields containing sterile other hand. instruments and supplies. j. Drop the towel into the linen hamper or into b. Perform surgical hand antisepsis. Dry hands the circulating nurse’s hand, making certain thoroughly. that hands did not fall below the waist level. c. Pick up the gown (folded inside out) from the 4. Perform spongeless surgical hand scrub with sterile package, grasping the inside surface alcohol-based hand rub product. at the collar. a. After pre scrub wash, turn on water using d. Lift folded gown directly upward and step foot or knee control. Clean under nails of back, away from the table both hands with disposable nail pick or e. Locate neckband; with both hands grasped cleaner and rinsed hands and forearms inside front of gown just below neckband. under running water. Dry your hands f. Keep the gown at arm’s length away from thoroughly with a paper towel. Turn off water. the body, allowing it to unfold with the inside b. The dispenser recommended an amount of of the gown toward the body. Do not touch antimicrobial agent hand preparation. Apply the outside of the gown or allow it to touch agent to hands and forearms according to the floor. manufacturer instructions for application, g. With hands at shoulder level, slip both arms recommended volume, and specified time. into armholes simultaneously. Do not allow c. Repeat antimicrobial product application if hands to move through the cuff opening. indicated in manufacturer instructions. Have circulating nurses pull gown over d. Rub thoroughly until completely dry. Proceed shoulders by reaching inside arm seams. to OR to don gloves. Pull gown on, leaving sleeves covering hands. Evaluation h. Have circulating nurse tie gown at neck and - Monitor the patient after surgery for signs of surgical waist. If the gown was wraparound style, do site infection (usually occurs 2-3 days after surgery). not touch the sterile front flap until the scrub nurse / technician is gloved. Recording 2. Apply gloves using closed-glove method: - No recording is required for surgical hand asepsis. a. With hands covered by gown cuffs and sleeves, open the inner sterile glove Hands Off Reporting package. - Record area and description of surgical site after b. Grasp folded cuff of glove for dominant hand surgery to provide baseline for monitoring wound. with nondominant hand. c. Extended covered dominant hand and forearm forward with palm up and placed palm of glove against palm of dominant Transcribed by: Michael Gabriel Jimenez | 2  hand. Glove fingers pointed toward the elbow. d. While holding the glove cuff through the gown with the dominant hand on which it is placed, grasp the back of the glove cuff with a nondominant hand and gown cuff. e. Grasp top of glove and underlying gown sleeve with covered nondominant hand. Carefully extend fingers into the glove, being sure that the cuff of the glove covers the cuff of the gown. f. Glove the nondominant hand in the same manner with gloved, dominant hand. Keep your hand inside the sleeve. Ensure that fingers are fully extended into both gloves. 3. Don wraparound gown: a. Grasp sterile front flap / paper tab with gloved hands and untied. b. Pass sterile paper tab to member of sterile surgical team or to non sterile team member. Keep the gown tie in your right hand. Circulating nurse stood still as the scrub nurse / technician turned. c. Allowing margin of safety, turn to left one-half turn, covering back with extended gown flap. Retrieve sterile tie only from team and secure both ties in place Evaluation - Monitor the patient after surgery for signs of surgical site infection (usually occurs 2-3 days after surgery). Recording and Reporting - No recording is required for sterile gowning and gloving. Record area and description of surgical site after surgery to provide baseline for monitoring wound. Transcribed by: Michael Gabriel Jimenez | 3 Transcribed by: Michael Gabriel Jimenez | 4  Day 2 : Instrumentation Surgical Instruments Types of Surgical Instruments (Categorized Based on Utility) Instruments may be used for: Manipulation Retraction Cutting Suturing Suction other purposes / miscellaneous Manipulation - As you hold and interact with objects in your hands, a surgeon may use the following instruments to interact, dissect and handle tissues or needles within the surgical field (the bit being operated on). Manipulation-to control or play upon by artful manner Dissecting Forceps Dissecting forceps are used to handle tissues and other materials and also to manipulate needles and other instruments whilst operating. A variety of forceps have been developed to suit different purposes and many of them are available in different lengths. The jaws of the forceps may be toothed, plain or have specialized grips. Inappropriate choice of forceps may lead to damage to tissues or to the instruments themselves. Also known as dissectors, pick-ups, grabbers and thumb forceps. This is one of the instruments you are most likely to be familiar with. Dissecting forceps look like a large pair of tweezers and generally vary in size and shape. Forceps are used to grasp and manipulate tissue as well as equipment such as needles or swabs. You would use them as you would use your finger and thumb. Importantly, the tip of the forceps can be non-toothed (atraumatic) or toothed (traumatic). The most commonly used non-toothed forceps are given the eponymous name ‘Debakey’s’. Adson’s Plain Forceps Fine dissectors often used in plastic surgery are useful for grasping delicate tissues to dissect out nerves and vessels. Adson’s Toothed Forceps Fine dissectors with teeth for gripping fine but tougher tissues. Often used in plastic surgery and useful for grasping fascia, subcutaneous fast and tendons. Bonney’s Toothed Forceps Heavy toothed forceps used for grasping larger tough tissue and handling heavy needles. Typically used on fascia such as when closing a laparotomy wound. Bonney Forceps: Heavy forceps used for holding thick tissue (e.g., fascial closure). Gillies Toothed Forceps Toothed dissector for general use on tougher tissues. The teeth mean that less pressure is required to adequately grip tough tissues such as skin but also that they are inappropriate for use on delicate tissue. Lane’s Forceps Heavy toothed forceps similar to Bonney's. McIndoe’s Forceps Non-toothed dissectors. Transcribed by: Michael Gabriel Jimenez | 5 DeBakey’s Forceps A forceps widely used in general abdominal and vascular surgery. Designed to grasp delicate tissues without trauma. They are available as fine or broad and in various lengths. Suitable for handling bowel, large blood vessels, bile ducts etc. Gerald’s Forceps Non-toothed dissectors used for handling delicate vessels and needles in vascular surgery. Plain Forceps Non-toothed broad dissectors are not usually used for dissection rather for handling packing gauze and prostheses. Bayonet Forceps A variety of scissors are available and are used for sharp dissection and cutting different tissues, sutures and prostheses. Inappropriate choice of scissors may lead to damage to tissues or to the scissors themselves. Tissue Forceps Tissue Forceps: Non-toothed forceps used for fine handling of tissue and traction during dissection. Tissue and Artery Forceps Forceps that are used to grasp and manipulate tissues vary in their design depending on the type of tissue they are intended for. As with all instruments, inappropriate use may lead to damage to tissues or to the instruments. Artery forceps are primarily used as hemostatic forceps to grasp vessels and allow ligation of those vessels. They vary in size for use on fine, delicate vessels to large vascular pedicles. Artery forceps can also be used to grasp tissues, sutures and other prosthetic materials. Care should be taken as they are crushing forceps that can damage delicate structures. Clamps (Also called locking forceps, these are ratcheted instruments used to hold tissue or objects, or provide hemostasis. Can be traumatic or atraumatic) Hinged Forceps Resembling a pair of scissors but instead of two blade-like parts, two arms which meet to press together instead of cut. The size and shape of the arms, as well as the shape of the surfaces which meet vary depending upon the type of hinged-forceps. This design is Transcribed by: Michael Gabriel Jimenez | 6 common amongst many instruments, for example, needle holders (for suturing, see below) and artery forceps (for vessel ligation). Allis Lightweight toothed forceps with a broad grasping area. Morrison Heavier toothed forceps used on tough tissues such as fascia or skin Kocher’s Strong toothed tissue forceps used for grasping tough fascia. Straight and curved Kocher's are available in varying lengths. Babcock Is used to grasp delicate tissue (intestine, fallopian tube, ovary). Available in short and long sizes. Are finger ring, ratcheted, non-perforating forceps used to grasp delicate tissue. They are frequently used with intestinal and laparotomy procedures. Babcock Forceps are similar to Allis forceps; however, may be considered less traumatic due to their wider, rounded grasping surface. Transcribed by: Michael Gabriel Jimenez | 7 Lane’s Heavy forceps with a single tooth. DuVal’s A light weight forceps with a large grasping surface to distribute force and reduce trauma to tissues. Often useful for grasping the stomach or lung. They will still damage more delicate tissues. Rampley’s Often used to hold prep sponges these long heavy forceps are also useful for grasping the gall bladder at cholecystectomy. Artery Forceps (Hemostat) Usually available as straight or curved. The smallest are known as mosquito forceps and they range through to 5 inch Crile's forceps and 7 inch long fine forceps. The curve allows easier placement of ligatures around the forceps. Transcribed by: Michael Gabriel Jimenez | 8 Kelly Clamp Larger size variation of hemostat with similar function for grasping larger tissues or vessels Curved - Kelly hemostatic forceps are used to clamp blood vessels and hold heavy tissues in place. Straight - Kelly Forceps are a general purpose EMS and surgical tool used to grasp very small objects when they are too large. They are used in surgery and in EMS operations to reach and grasp in the tightest areas. Kelly Forceps This instrument can be used as a clamp, heat sink, or third hand. Mosquito Forceps Curved - Hemostat Mosquito Curved Forceps 5": Multipurpose instrument used to clamp off blood vessels, remove small root tips and grasp loose objects. Straight - used as a hemostatic agent to compress smaller vessels that regulate blood flow Shod Forceps To avoid damage to sutures, particularly useful in vascular surgery, rubber boots are applied to the jaws of an artery forceps. This allows the suture material to be clamped without significant damage. Towel Clamps Backhaus towel clamp is a perforating clamp. It is used for grasping the tissue, securing towels or drapes, and holding or reducing small bone fractures. Backhaus Towel Clamp is mainly used to fasten drapes or towels to patients during medical procedures in order for them to stay on. Lorna or Edna towel clamp is used for securing towels, drapes, tubing and equipment near the surgical site. Other applications include attaching suction, electrosurgical, and camera cords to drapes. Are a non-perforating clamp used to secure instruments and surgical materials such as tubing and towels to the drape surrounding a surgical site. Transcribed by: Michael Gabriel Jimenez | 9 Probes Long, slender and uncomplicated instruments, probes also vary in size and the functional ends Generally, probes are used for exploring or examining anatomy as well as fistula or sinus tracts. Retraction - Retractors, in varying forms, are used to hold an incision open, hold back tissues or other objects to maintain a clear surgical field, or reach other structures. They can either be hand-held or self-retaining via a ratcheting mechanism. To improve the view of the surgical field by tissue or organs out of the way the following instruments may be used; Handheld Retractors The hand held retractor is a versatile instrument that can be readily moved and manipulated and it applies as much or as little force as desired. There are many different designs suited to different purposes. Simple, versatile instruments which need to be held and manipulated by an assistant. They have three main parts: 1. a handle which goes in the assistant’s hand, 2. a blade which goes into the patient and 3. a shaft in-between The blades come in many different shapes, including hooks, teeth, right angles and curves. Langenbeck's Available in different sizes these retractors are useful for retracting superficial wound edges. Army pattern Also known as Durham-bar, Kenny-Ryles and army navy these double ended retractors are frequently used to retract wound edges. Army-Navy Retractor: Used to gain exposure of skin layers. S shaped Predominantly used during open dissection for Hassan cannula insertion at laparoscopic surgery. Each end of the S has a slightly different curve. Transcribed by: Michael Gabriel Jimenez | 10 Fritsch's A curved retractor designed for use on the body wall. Deaver's A curved retractor available in various widths and curvatures. A general purpose abdominal retractor. Deaver Retractor: Used to hold back the abdominal wall. Cat's paw The Senn-Mueller retractor commonly known as a "cat's paw" is a double ended small retractor for skin retraction in small and delicate wounds. Skin hooks The dissecting tenaculum is available as single or double pronged and is designed for skin retraction and usually used in plastic and hand surgery. St Mark's A lipped, right angled pelvic retractor. It also frequently incorporates a fiber optic light carrier. Used in deep pelvic surgery such as rectal dissection. Kelly's A curved right angled retractor. Used in deep pelvic surgery such as rectal dissection. Copper malleable Essentially a flat piece of soft, malleable metal that is able to be shaped as desired. Available in different widths it is often bent into a hook over another retractor. Also known as ribbon. A retractor that comes in various widths and lengths, used in abdominal and thoracic. It is Flexible. Malleable Retractor: Can be bent and customized. Also used to protect intestines during abdominal closure. Transcribed by: Michael Gabriel Jimenez | 11 Scapula The Tudor-Edwards scapula retractor is used whilst making a thoracotomy to elevate the scapula and lift it off the chest wall. Lung The Allis lung retractor is used at thoracotomy to gently retract the lung. It may be covered with a damp cotton sleeve to further protect the lung. Rake These retractors are available with 3 to 6 teeth and provide excellent retraction to skin edges. Richardson Richardson Retractor: Used to hold back deep tissue structures. Also called “Rich.” Retract abdominal or chest incisions. Used for holding back multiple layers of deep tissue. This is one of the most common general retractors. Goulet Retractor Are double-ended hand-held devices that are used in general surgical procedures to mobilize soft tissues while avoiding damage to their underlying structures. Weitlaner Retractor Weitlaner Retractor: Self Retaining for exposing deep or smaller surgical sites. Also called “Wheaty.” Gelpi Perineal Retractor The Gelpi Retractors are used for holding back tissue and organs during spine surgical procedures. The locking mechanism keeps the tool in space and provides exceptional hold for the surgery. Transcribed by: Michael Gabriel Jimenez | 12 Bladder Retractor An internal bladder retractor was used to facilitate dissection of the vascular pedicles during laparoscopic radical cystectomy in a female patient. Results: The application of the retractor is easy and it allows more precise control of the vascular pedicles and ureters. Self-Retaining Retractor Varying significantly in design from simple hinged ratchet’s to complex operating-table-mounted frames, self-retaining retractors hold themselves in place after they have been positioned and applied This is very useful, as it frees up the assistant’s hands to do other more exciting things, reduces muscle fatigue and allows the continuous provision of safe and stable levels of traction during longer procedures. Balfour With Bladder Is a surgical instrument designed to Blade Retractor retract bulky tissues with ease. It is commonly used during urological, gynecological and general surgeries to retract internal organs and tissues to enhance the view of the surgical field. Bookwalter Retractor Bookwalter Retractor: Self-retaining retractor system that is anchored to the operating table. Cutting - To open up tissue, such as the skin during the beginning of an operation in the abdomen, and also to separate tissues apart during an operation. Scissors Whilst it would be an almost incredible feat to have never used or seen scissors in your life up to now, there are many different types of surgical scissors. The majority look like simple metal scissors, though curved and angled scissors are also commonly used. It's important to know that suture scissors are generally straight, and fine dissecting scissors have a slight curve at the tip. Don’t forget that surgical scissors, and most instruments for that matter, are right-handed instruments. Scissors are used for cutting tissue, suture, or for dissection. Scissors can be straight or curved, and may be used for cutting heavy or finer structures. Transcribed by: Michael Gabriel Jimenez | 13 Metzenbaum Scissors Fine scissors used for general sharp dissection. Available in varying lengths. Metzenbaum Scissors: Lighter scissors used for cutting delicate tissue (e.g., heart) and for blunt dissection. Also called “Metz” in practice. Curved Mayo Scissors Heavy curved scissors favored by some for general abdominal dissection. Curved scissors are used for cutting heavy tissue (e.g., fascia). Straight Mayo Scissors Heavy straight scissors typically used to cut sutures and prosthetic materials rather than for dissection. Straight scissors are used for cutting suture (“suture scissors”). Potts’s Scissors Fine sharp straight scissors used for arteriotomies in vascular and cardiac surgery. Also appropriate for other delicate tubular structures such as the bile duct and ureter. Typically a sharp blade is used to make the initial incision (No 11 or 15) which is then extended with the scissors. These scissors are available in various sizes and with the jays angled to a variable extent including a reverse cutting version. Pott’s Scissors: Fine scissors used for creating incisions in blood vessels. Curved and Straight Iris Scissors Used for fine dissection and cutting suture. Originally for ophthalmic procedures, but now serves a multipurpose role. Transcribed by: Michael Gabriel Jimenez | 14 Spencer Suture Scissors Spencer Stitch Scissors are available with a delicate, regular, or slender pattern and are primarily used for suture removal. The Spencer Scissors have a small hook-shaped tip on one blade that slides under sutures to slightly lift them before cutting for removal. Lister Bandage Scissors Used to remove bandages and dressing, the blunt probe pointed blade can easily be inserted under the bandage without injury to the skin. Bone Cutter A bone cutter is a surgical instrument used to cut or remove bones. In addition to surgery, they are also used in forensics and dismemberment. Scalpel The blades themselves come as disposables whilst scalpel handles are often within an instrument set, often called a ‘B.P. handle’. They vary in size and how they are best held, so have a close look at how the surgeon holds the scalpel. Scalpel is used for initial incision and cutting tissue. Consists of a blade and a handle. Surgeons often refer to the instrument by its blade number. Scalpel / Blade Holder #3 The #3 knife handles are used to hold blades 10 thru 15. These knife handles are used to create incisions, transecting, or dissecting. *b10-Open surgery *b11-Stab/Minimal *b15-excision Transcribed by: Michael Gabriel Jimenez | 15 Scalpel / Blade Holder #4 Size #4 scalpel blade handles are designed to fit a range of scalpel blade sizes. Podiatrists often use size #23 blades which fit on a size #4 scalpel handles. Other compatible scalpel blades sizes include No. 18, 19, 20, 21, 22, 22A, 24, 25, 25A, 26, 27 and 36. *First knife Blades Examples of different sized and shaped blades are shown here. Other blades are available for specific uses. #10 Blade: Used primarily for making large skin incisions, e.g., in laparotomy. #11 Blade: Used for making precise or sharply angled incisions #15 Blade: Smaller version of #10 blades used for making finer incisions. Suturing - Sutures are medical devices which are used to sew living tissues. - They essentially consist of a needle and a thread, known as the suture material. Sutures can hold wound edges together while healing, control bleeding, repair tissue defects or damaged structures, create anastomoses and secure foreign objects such as mesh implants, vascular grafts and drains in place. - Suturing is a core surgical skill and one of the first techniques surgeons are taught during their training. In addition to perfecting the physical art of suturing, surgeons must make important decisions about the best suturing methods to use and which of the vast array of available needles and suture materials to choose for each step of an operation. - Needles come in many shapes and cutting edges for various applications. Suture can be absorbable, non absorbable, and is available in different sizes. Types of Needles - Needles must dissect through tissue to pass suture. They come in various sizes, types, and shapes depending on the application. Here are a few (though not all) examples: Transcribed by: Michael Gabriel Jimenez | 16  1. Tapered Needle 2. Conventional Cutting Needle Suture Needle Shapes - The shape of the needle is also important. The curvature of the needle allows for use in specialized applications. Curved needles are used in most general surgical procedures, while straight needles are used for skin and subcuticular suturing. - The amount of space available in the operative field will dictate the best needle shape to use. 1. Curved Needles - Curved needles are by far the most common type. They can be maneuvered easily in small spaces and allow the surgeon to take decent bites of tissue by turning their wrist. - Smaller curves (such as ⅜ or ½ of a circle) are suitable for most tasks, whilst larger curves (such as ⅝) are better for very narrow or deep spaces. J-shaped needles are perfect for fascial closure of small laparoscopic port sites. Ski-shaped needles are very useful for laparoscopic suturing, where the surgeon cannot use their wrist to drive a curved needle as effectively. 2. Straight needles - Straight needles can be held with a needle holder or in the surgeon’s hand. They are very precise and create beautifully neat skin closures. However, they are unsuitable for deeper suturing within body cavities as they require a lot of space to maneuver and are more likely to inadvertently prick organs. (from left to right) a large ⅝ curve, a J-shaped curve, a straight needle and a smaller ⅜ curve Parts of a Suture Needle Suture needles - Any sort of sewing requires a needle to carry the thread through the tissues. Suture needles are made from stainless steel alloys and have three parts: - a narrow point which is driven into the tissue - a wider body which is grasped by the needle holder - a swage where it joins with the suture material Transcribed by: Michael Gabriel Jimenez | 17  Types of Suture Suture Removal Time - Face - 3 to 5 days - Scalp - 5 days - Trunk - 7 to 10 days - Arm and Legs - 7 to 10 days - Foot - 10 to 14 days Hinged Suturing Forceps - Needle holders are a specific type of hinged-forceps that are specifically designed to hold suture needles between their teeth. They are used for passing needles through tissue when suturing. Transcribed by: Michael Gabriel Jimenez | 18  Suction - Suction tips, combined with a suction source, help to remove debris and fluid from the surgical field. It can also be used to clear surgical smoke. Yankauer Suction Tube Yankauer Suction Tube: Used primarily for surface suction and some intra-abdominal suction. Poole Suction Tube Poole Suction Tube: Used to remove large amounts of fluid from the surgical field, as well as intra-abdominal suction. Frazier Suction Tip Frazier Suction Tip: Used primarily in ENT and neurosurgery. Usually angled. With a finger controlled side hole this fine Frazier suction is able to be used in confined spaces and for accurate suction Transcribed by: Michael Gabriel Jimenez | 19 Surgical Suction Suction is used to clear the surgical field by removing blood or other fluids. The suction tip is attached to a vacuum piping outside of the sterile field. There are many different shapes of suckers (small and fine-tipped, or large to prevent blockages) depending on the operation being performed Miscellaneous - Towel clips (for attaching things onto drapes): akin to small forceps that hold together different sections of the drape material used to cover a patient during operations - Hammers: of various shapes, most often used in orthopedics for driving nails into bone, or alongside a chisel in amputations - Drills: cordless battery-operated drills are used to drive screws into bone and also create boreholes in the skull during neurosurgery - Saws: these come in both battery-operated and manual versions, such as the Gigli saw, commonly used in amputations - Dilators: blunt probe-like instruments used for stretching lumens, such as the urethra. - Tunnellers: long hollow tube-like instruments that can be pushed under the skin, once in place drains can be placed through them before removal of the tunneller device Skin Glue and Stapler For skin closures, in particular, staplers and skin glue may be used in lieu of suture. This is usually based on cosmetic outcome and surgeon preference. Linear Stapler and Linear Cutter Linear Stapler: Creates a linear staple line; no cutting function. Used in ligation and anastomosis. Maybe curved. Linear Cutter: Creates a linear cut and immediately staples both free edges. Used in separation and anastomosis Transcribed by: Michael Gabriel Jimenez | 20 Circular Cutter and Clips Circular Cutter: Performs circular cut and staple. Used in reanastomosis of hollow viscera, e.g., large bowel. Clips: Used in the ligation of vessels, may be metal or absorbable material. Open and lap applicators. Energy Systems - Broad term used to describe various methods of cutting tissue or sealing vessels. May use electricity or sonic waves. Available in open or laparoscopic forms. Diathermy An energy device which is commonly used to cut through tissue, but has both cutting and coagulation properties. It works by a high-frequency electrical current which heats the tissue to which it is applied. The options for cutting or coagulation make different sounds when they are being deployed. The two main types of diathermy are bipolar and monopolar. 1. Monopolar is probably used most commonly and requires a conduction pad to be applied to the patient to complete the electrical circuit. You might see this pad being placed before the patient is draped. 2. Bipolar is often used for finer work and is commonly deployed with ‘bipolar forceps’ where the energy travels between the tips of the forceps to heat the tissue between them. Electrosurgery Electrosurgery: Instrument that cuts or cauterizes tissue via an alternating electrical current. Open (shown) and laparoscopic (Ligasure®) applications. Ultrasonic Ultrasonic: (Harmonic®) uses high frequency sound to concurrently cut and seal tissue. Less thermal spread than electrosurgery, but more time consuming. Endostapler Endostapler: Used in laparoscopic procedures, provides simultaneous cutting and stapling. Maybe manual or electronic. Some feature articulating heads to accomplish more difficult placement. Disposables Alongside instruments used for every operation, there are many single-use items. General examples of such items include swabs (single-use for infection control reasons) and hemoclips (or endoclips) which remain inside the patient. Disposables generally fall into two categories; cheap and expensive. Cheap disposables include things such as swabs and pledgets (radio-opaque stitched gauze – of various sizes), hemoclips which can be used to hold vessels shut as an alternative to ties or sutures and dressings. Expensive disposables tend to be staplers or single-use surgical instruments, some of these instruments cost thousands of pounds (so definitely Transcribed by: Michael Gabriel Jimenez | 21 something to avoid dropping!). Transcribed by: Michael Gabriel Jimenez | 22  Day 3 : Hemodialysis and Peritoneal Dialysis A. Inspection Two Types of Dialysis - The physical exam of a dialysis fistula or graft begins 1. Hemodialysis with inspection. Look for any bleeding, swelling to 2. Peritoneal Dialysis indicate aneurysm or pseudoaneurysm, and any recent incisions/scars Indications: - The arm elevation test evaluates for venous - Acidosis obstruction. A normal access will collapse when the - Electrolytes patient’s arm is elevated above their head. A - Ingestions stenotic/thrombosed access will remain - Overload swollen/dilated or collapse very slowly. In addition, - Uremia patients with venous obstruction will have a strong pulse but diminished or absent thrill, as well as a Hemodialysis short, high-pitched whistling bruit - For patients living with end-stage renal disease - Patients with an abnormal pulse augmentation test (ESRD), dialysis access management is extremely likely have arterial obstruction. Normally, compression important. Many ESRD patients require hemodialysis of the access distal to the access site/anastomosis (HD) treatments – a process in which blood is should result in augmentation of the patient’s pulse transported from your body for cleaning. A vascular when palpated proximally as well as loss of thrill. access is created so that blood can be drawn from the Patients with arterial obstruction will already have body and run through a dialysis machine, where hyper pulsatility and therefore will have no change in excess fluid and toxins are removed from the blood. pulse when the access is compressed (i) The filtered blood then flows back through the access into the body. Three Different Hemodialysis Accesses 1. Arteriovenous Fistula (AV fistula) 2. Arteriovenous Graft (AV graft) 3. Central Venous Catheter (CVC) - Dialysis access is essentially a dialysis patient’s lifeline to treatment and good health and having a well-functioning access that handles adequate blood flow allows for the most effective dialysis treatment. Arteriovenous Fistula (AV fistula) - A fistula is a surgical connection between two native vessels in the patient’s arm, which has matured over A. Palpation months requiring plenty of time to plan and map the - Next palpate the access, which should be soft and patient’s vessels as an outpatient. easily compressible throughout. It should have a soft equal palpable pulse throughout as well as a Arteriovenous Graft (AV graft) continuous thrill (or vibration) best felt at the arterial - A graft instead is a synthetic connection between two anastomosis. vessels in the patient’s arm, also surgically placed but only requiring a few weeks to mature. It is prone to complications due its being a foreign body in the patient. Assessment (Fistula & Graft) Transcribed by: Michael Gabriel Jimenez | 23 B. Auscultation - Rope-ladder has always been referenced as the - Lastly, auscultate the access for a bruit – normally a preferred technique for vascular access cannulation. continuous low pitched sound indicating free flow This technique consists of using the entire extension throughout the access (2). of the available vessel by progressive rotation of the puncture points. This method is not always used, due to resistance from patients, considering that it is very painful - The BH technique, initially described in 1977 and later by Z.J. Twardowski, is referred to as a CT that is always performed in the exact same place and with the same inclination and depth. This technique has some limitations since it must be used exclusively in AVF and requires the cannulation to be performed by the same nurse until the tunnel is built and is time-consuming. Early research indicated that it was a promising CT, with reduction in the number of bruises and reduction in failed cannulation, and was preferred Arteriovenous Graft (AV graft) by nurses when compared to the other two techniques. Augmentation Test Do Not Cannulate Signs and symptoms of severe infection Signs and symptoms of a localized, superficial infection that is on or near the needling site. Absence or poor quality of bruit and thrill Extreme edema or other factors (e.g., rash or unexplained aneurysm) which would render cannulation inappropriate. Proceed But Consult MD Signs and symptoms of a localized, superficial Maturation of Arteriovenous Graft infection that is not on or near the needling site. A pulse is palpated instead of a thrill, and is abnormal for the access in question A significant increase in pitch is noted on auscultation Aneurysm (AVFs) or pseudoaneurysm formation (AVGs) Difficulties in cannulation, despite the use of advanced cannulators Inability to achieve expected blood pump speeds while on dialysis Low arterial or high venous pressures on 3 consecutive runs Cannulation Unexplained, prolonged bleeding (>10-15 min) from - Cannulation techniques are known: rope-ladder (RL), cannulation site on 3 consecutive run (may be buttonhole (BH), and area puncture. indicative of stenosis. Transcribed by: Michael Gabriel Jimenez | 24  Caring For Fistula Caring For Graft Wash with antibacterial soap before dialysis. Wash with antibacterial soap before dialysis. Inspect access site for changes in appearance. Inspect access site for changes in appearance. Advice the patient not scratch skin or pick a scab. Advise the patient not scratch skin or pick a scab. Advise the patient to avoid clothing that rubs against Advise the patient to avoid clothing that rubs against access and not to sleep in a position that irritates access and not to sleep in a position that irritates access. access. Do not use the arm for venipuncture / BP monitoring. Do not use the arm for venipuncture / BP monitoring. Rotate the needle placement sites during dialysis Rotate the needle placement sites during dialysis treatment. treatment. Bleeding Central Venous Catheter (CVC) - If there is so much bleeding that you cannot identify - A CVC is normally used when dialysis is urgent. A the location, use your fingers at the proximal and CVC is a long, flexible, Y-shaped tube that is inserted distal ends of the access to temporarily cease blood through your skin into a central vein in your chest, flow while a colleague finds the source. And don’t neck, or in some situations, the groin. Your vascular forget to have the patient raise their arm above their specialist will instruct you on how to keep your head/heart or do this for them. catheter clean and intact between dialysis sessions. - If this is unsuccessful, most vascular surgeons would - A catheter may have been placed for emergent place a “figure-of-8” stitch. dialysis when a patient presents late in their disease - Common causes of bleeding include aneurysms, course and has not undergone mapping and access pseudoaneurysms, supratherapeutic anticoagulation, planning. These can be tunneled (placed by and anastomotic rupture. If the bleed is small, venous, interventional radiology or surgery) for use as an and easily controlled, then it might not be necessary outpatient or non-tunneled for short term/emergency to do any additional work-up in the ED. However, use. blood testing and arterial doppler ultrasound may be used to evaluate for these causes in the stabilized The Advantages of a CVC patient, in conjunction with vascular surgery when - Immediate access appropriate. The arterial doppler ultrasound is more - Long term access likely to happen if the patient is admitted, but vascular - No needles surgery may request that you help expedite the test if it will change their management. If your patient is The Disadvantages of CVC hypocoagulable and has an arterial bleed, consider - Serious infection from CVC reversal of the causative agent. - Risk of clots - Damage to blood vessels Controlling the bleeding is the first concern. Assessment and determination of why the bleeding occurred can be determined later when the patient is more stable. Direct pressure, ideally with one finger or small square of gauze, should be attempted for 15-20 minutes for any venous bleeding. Transcribed by: Michael Gabriel Jimenez | 25  Caring for Central Venous Catheter (CVC) 1. Hand hygiene. 2. Avoid using sharp objects, such as scissors, near CVC. - End-stage renal disease affects the body’s natural 3. Keep the CVC covered and secured to the body to immune system, increasing the risk of developing prevent it from being pulled or tugged. infections, including antibiotic-resistant infections. 4. Flush the catheter using a saline solution consisting of Infection is the most common cause of death for salt and water, and heparin. dialysis access patients. Along with clotted access 5. Change the dressing for every treatment. Be sure to and bleeding—it is among the most common wear a mask and gloves. Use alcohol pads and a complications for all vascular access types. cleaning solution approved by a doctor. - In fact, rates of hospitalization for infection for dialysis 6. Keep the dressing clean and dry always. Instruct the patients have increased 43 percent since 1993. patient not to wet the area and swimming is not - Risk factors for developing an AV fistula or graft allowed. infection include: 7. Keep the clamps on the catheter tubes always closed a. Poor hygiene unless the catheter is being used. b. Diabetes 8. Look for signs of infections. c. Skin wound 9. Wear loose, comfortable clothing that won’t get d. Having a buttonhole access, a type of caught in the catheter. access that creates a “tunnel” of scar tissue for the dialysis needle to be placed through. Risks Associated With Hemodialysis Hypotension Peritoneal Dialysis Anemia Muscle cramps Difficulty sleeping Itching Hyperkalemia Pericarditis Sepsis Bacteremia Irregular heartbeat Sudden cardiac arrest Signs Of Infection Swelling or redness of access arm or hand and the access site area Soreness or tenderness at the access site Any drainage or pus along the access Redness starting from access site and spreading outward A feeling of excessive warmth surrounding your access site and in arm and hand Fever Transcribed by: Michael Gabriel Jimenez | 26  Materials Caring For PD Catheter Caring for PD catheter is extremely important following its placement since PD is linked to a high risk for infection at the catheter exit site, in the tunnel for the catheter, and in the What is a PD catheter? peritoneum. This type of abdominal infection is known as - Your PD catheter is a flexible plastic tube. peritonitis. - Wash hands thoroughly with soap and water before How Does It Work? and after handling the catheter. - The PD catheter is placed through the wall of the - Clean access site every day to eliminate bacteria. abdomen into the peritoneal cavity. - Store dialysis supplies in a clean, dry, and cool place. - It allows dialysate to enter abdomen and clean waste - Perform dialysis in clean, dry places that are well lit to products from blood. reduce contamination risk. - Dialysate remains inside the abdomen for a length of - Wear a surgical mask each time when opening the time prescribed by the doctor. end caps of the PD catheter. - It then drains out of the abdomen through the catheter - Thoroughly inspect every bag of solution for signs of into a drainage bag and is discarded. cloudiness and contamination before use. - Avoid wearing tight, restrictive clothing and belts near Types of Peritoneal Dialysis the access site. 1. Continuous ambulatory peritoneal dialysis - Keep sharp objects like scissors away from your (CAPD) catheter at all times. - Your abdomen is filled and drained multiple - Keep the catheter taped against your skin to prevent it times daily. This method doesn’t require a from catching on clothing and other objects. machine and must be performed while awake. Care After Insertion 2. Continuous cycling peritoneal dialysis (CCPD) - After the catheter is inserted, the insertion site is - Uses a machine to cycle the fluid in and out usually covered with a gauze dressing and tape to of your abdomen. It’s usually done at night prevent the catheter from moving and to keep the while you sleep. area clean. For the first seven to ten days after the 3. Intermittent peritoneal dialysis (IPD) catheter insertion, dressing should be left alone and - This treatment is usually performed in the first changed by a specialist seven to ten days after hospital, though you may perform it at home. placement using sterile technique. It uses the same machine as CCPD, but the - The area should be kept dry until it is well healed, process takes longer. usually for 10 to 14 days. Advise patient not to take a shower or bath or go swimming during this time. A washcloth or sponge may be used to clean the body, careful to keep the catheter and dressing dry - Teach client to limit lifting and vigorous exercise. Long Term Care - After the catheter site has healed, instruct patient on catheter exit-site care, to keep the area clean to minimize the risk of skin infection, as well as peritonitis. Transcribed by: Michael Gabriel Jimenez | 27  - In addition, recommend to “anchor” the catheter with important to note for any abnormalities present and tape to stabilize the catheter and minimize the chance take appropriate actions if needed) of movement causing injury to the healed exit site. 5. Ensure that a sign is placed over the head of bed - The skin around the catheter site should be cleaned informing the healthcare team which arm is affected. daily or every other day with antibacterial soap or an Do not perform a venipuncture or start an IV on the antiseptic. access arm. (Rationale: It creates an alteration to the - Before cleaning the area, wash hands with soap and flow in the access site.) water and put on clean gloves. 6. Instruct patient not to sleep with the arm with the - Hold the catheter still during cleaning which helps access site under head or body. (Rationale: It creates prevent injury to the skin. an alteration to the flow in the access site.) 7. Instruct the patient not to lift heavy objects with or put The soap should be stored in the original bottle (not poured pressure on the arm with the access site. Advise the into another container). Other types of cleansers, such as patient not to carry heavy bags (including purses) on hydrogen peroxide or alcohol, should NOT be used unless the shoulder of that arm. (Rationale: It creates an directed by your dialysis team. A clean cloth or towel is alteration to the flow in the access site.) suggested. 8. Remove gloves and perform hand hygiene.. (Rationale: Reduces the microorganisms and - Do not pick at or remove crusts or scabs at the site. prevents cross-contamination when handling other - Pat the skin until dry around the site after cleaning. patients) - Apply antibiotic cream (if prescribed by the dialysis 9. Document the procedure done, assessment findings care team) to the skin around the catheter with a and any patient education performed. (Rationale: To cotton-tip swab every time the dressing is changed. provide an accurate record of findings and for legal - Teach client to remember to always follow doctor's purposes.) instructions when it comes to caring for a PD catheter at home. Skills Demonstration Procedure Caring for a Peritoneal - Daily inspections of access site should be done to Dialysis Catheter remain healthy and free from infection. 1. Greet and identify the patient. Explain the procedure and encourage patient to observe or participate if An infection can happen even when taking the very best care possible. (Rationale: Promotes client participation; To of your PD catheter and adhering to good hygiene. build trust and rapport with the client and family) 2. Bring the necessary equipment to the bedside. Close Risks Associated with Peritoneal Dialysis curtains around bed and close door to room if - infections in or around the catheter site (peritonitis) possible. (Rationale: For a smooth and efficient - abdominal muscle weakening procedure, to provide privacy) - high blood sugar due to the dextrose in the dialysate 3. Perform hand hygiene and put on non-sterile gloves. - weight gain from dextrose and excess fluids (Rationale: Reduces the number of microorganisms.) - nausea or vomiting 4. Raise the bed to a comfortable working height. - Hernia (Rationale: Promotes ease in movement of nurse; - Fever prevents back strains) - stomach pain 5. Assist the patient to supine position. Expose the abdomen, draping the patient’s chest with the bath Skills Demonstration Procedure Caring for a Hemodialysis blanket, exposing only the catheter site. (Rationale: Access Ensures comfort and privacy to the patient) 1. Greet and identify the patient. Explain the procedure 6. Put on one of the face masks; have patient put on the and encourage the patient to observe or participate if other mask. (Rationale: Promotes protection both for possible. (Rationale: Promotes client participation; To the health care provider and client) build trust and rapport with the client and family) 7. Gently Remove old dressing, noting odor, amount and 2. Close curtains around the bed and close the door to color of drainage, leakage, and condition of skin the room if possible. (Rationale: To provide privacy) around catheter. Discard dressing in appropriate 3. Perform hand hygiene. (Rationale: Reduces the container. (Rationale: Inspection of old dressing is number of microorganisms.) important to note for any abnormalities present and 4. Inspect area over access site for any redness, take appropriate actions if needed) warmth, tenderness, or blemishes. Palpate over the 8. Remove non-sterile gloves and discard. Set up sterile access site, feeling for a thrill or vibration. Palpate field. Open packages. Using aseptic technique, place pulses distal to the site. Auscultate over access site two sterile 4×4s in basin with antimicrobial agent. with bell of stethoscope, listening for a bruit or Leave two sterile 4×4s opened on sterile field. Place vibration. (Rationale: Inspection of access site is sterile applicator on field. Squeeze a small amount of the topical antibiotic on one of the gauze squares on Transcribed by: Michael Gabriel Jimenez | 28  the sterile field. (Rationale: Aseptic technique 4. Assess access site to note for any abnormalities promotes a sterile environment which diminishes the present. risk of causing infection to the patient) Inspect for signs of infection 9. Put on sterile gloves. (Rationale: Aseptic technique Palpate access site and note for the promotes a sterile environment which diminishes the presence of a thrill or vibration risk of causing infection to the patient) Palpate pulses distal to the site 10. Pick up dialysis catheter with non-dominant hand. Auscultate access site -listen for bruit or With the antimicrobial-soaked gauze or swab, cleanse vibration the skin around the exit site using a circular motion, 5. Place a sign over the head of the bed of the patient to starting at the exit site, and then slowly going outward know which arm is affected 3" to 4". Gently remove crusted scabs if necessary. 6. Do not perform venipuncture on the access arm (Rationale: Principle of cleaning from the cleanest to 7. Do not sleep with the access site under head or under dirtiest site promotes the effective removal of the body microorganisms) 8. Do not lift heavy objects using the arm with access 11. Continue to hold catheter with non-dominant hand. site After skin has dried, clean the catheter with an 9. Remove gloves and perform hand hygiene antimicrobial-soaked gauze, beginning at the exit site, 10. Document going around catheter, and then moving up to end of catheter. Gently remove crusted secretions on the CARING FOR A PERITONEAL tube if necessary. DIALYSIS CATHETER 12. Using the sterile applicator, apply the topical antibiotic to the catheter exit site, if prescribed. Goal 13. Place the sterile drain sponge around exit site. Then - PD catheter dressing change is completed without place a 4×4 over exit site. Remove your gloves and trauma to the site as well as the patient secure edges of gauze pad with tape. Some - Clean, dry and intact site without signs of infection institutions require placing a transparent dressing - Patient exhibits fluid balance and participate in their over the gauze pads instead of tape. Remove mask. own care 14. Coil the exposed length of tubing and secure to the dressing or patient's abdomen with tape. Nursing considerations 15. Assist the patient to a comfortable position. Cover the - Care is performed daily or 3 or 4 times weekly during patient with bed linens. Place the bed in the lowest bathing position. - Catheter site should not be submerged in water 16. Put on clean gloves and dispose of equipment per - Liquid soap and water facility policy. Remove gloves and perform hand - "Make sure that catheter is secure to avoid tension hygiene. (Rationale: Reduces the microorganisms and trauma and prevents cross-contamination when handling other patients.) Procedure 17. Document the procedure done, assessment findings 1. Introduce self, identify patient, and explain the and any patient education performed. (Rationale: To procedure provide an accurate record of findings and for legal 2. Prepare equipment to the bedside purposes.) 3. Provide privacy 4. Hand hygiene, put on clean gloves 5. Raise the bed to a comfortable working height 6. Place patient on supine position CARING FOR A HEMODIALYSIS 7. Put on mask ACCESS 8. Remove old dressing and take note of abnormalities 9. Remove non-sterile gloves and discard. Set up a Goal sterile field. Open packages. Using aseptic technique, - The patient verbalizes appropriate care measures and place two sterile 4×4s in a basin with an antimicrobial observations to be made, demonstrate care agent. Leave two sterile 4x4s opened on a sterile measures, and the graft or fistula remains patent field. Place a sterile applicator on the field. Squeeze a small amount of the topical antibiotic on one of the Procedure gauze squares on the sterile field. 1. Introduce self, identify the patient and explain the 10. Put on sterile gloves procedure to be done 11. Pick up dialysis catheter with non-dominant hand. 2. Provide privacy With the antimicrobial-soaked gauze or swab, cleanse 3. Perform hand hygiene the skin around the exit site using a circular motion, starting at the exit site, and then slowly going outward Transcribed by: Michael Gabriel Jimenez | 29  3" to 4". Gently remove crusted scabs (on skin) if necessary. 12. Continue to hold the catheter with a non-dominant hand. After the skin has dried, clean the catheter with an antimicrobial-soaked gauze, beginning at the exit site, going around the catheter, and then moving up to the end of the catheter. Gently remove crusted secretions on the tube if necessary. 13. Apply the prescribed topical antibiotic to the catheter exit site using sterile applicator 14. Place the sterile drain sponge around the exit site. Then place a 4x4 over the exit site. Remove gloves and secure edges of gauze pad with tape. Some institutions require placing a transparent dressing over the gauze pads instead of tape. 15. Coil the exposed length of tubing and secure to the dressing or patient's abdomen with tape 16. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position. 17. Put on clean gloves, dispose of equipment. 18. Remove gloves, perform hand hygiene. 19. Document. Transcribed by: Michael Gabriel Jimenez | 30  Day 4 : Capillary Blood Glucose Monitoring Joint Commission standards and improves patient Diabetes safety.) 2. Review patient’s EHR for health care provider’s order for time or frequency of measurement. (Rationale: Health care provider determines test schedule on basis of patients’ physiological status and risk for glucose imbalance.) 3. Review patient’s HER to determine if risks existed for performing skin puncture. (Rationale: For some critically ill patients, handheld point of care (POC) glucometers yield inconsistent results when the patient has low hematocrit levels or is hypotensive; when the patient is taking vasopressors, ascorbic acid, or other medications; or when capillary blood specimens as opposed to arterial or venous blood Indications samples are used. These factors can potentially lead Patients with Diabetes to incorrect insulin dosing. For the most accurate Women with Gestational diabetes (similar to type 2 results use arterial or venous blood samples.) diabetes but occurs only during pregnancy) 4. Determine if specific conditions needed to be met - Patients who are being treated for diabetes with before or after sample collection. (Rationale: Dietary insulin or oral blood sugar control drugs, pregnant intake of carbohydrates and ingestion of concentrated women diagnosed with gestational diabetes can try glucose preparations after blood glucose levels.) one to several times a day In cases where they are 5. Assess patient’s / family caregiver’s